This is the concluding installment in a series on drugs in Alberta. Previously:

i. “Worse Than I’ve Ever Seen,” June 4

ii. “Alberta’s System Builder,” June 7

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A matter of expectations

Street family

My tour guide for much of my visit to Edmonton was Dr. Monty Ghosh, a clinician who’s on faculty at the University of Calgary and the University of Edmonton. He seems to talk to everybody who works with substance users in Alberta, from his own patients to front-line clinicians to the Alberta government. His relations with the latter go up and down, but he urged me to talk to Marshall Smith, the chief of staff to premier Danielle Smith.

On my first night in Edmonton Ghosh walked me around a neighbourhood that included the George Spady Society  supervised-consumption site, the Hope Mission’s Herb Jamieson Centre, and the Royal Alexandra Hospital, which has a supervised-consumption service on its premises.

A lot of people use the services these places provide. Other people don’t. Shelters in particular are tricky: they’re usually for single people who arrive alone. “The Hope, the Herb, the Navigation Centre, offering the world,” one Edmonton Police Service officer told me. “But all these places have one thing in common: rules.” If you have a spouse or a pet, you want to keep your drug supply or you want to stay close to your “street family” — the community spirit in neighbourhoods like this is striking, and might be surprising to people who prefer to stay away — a shelter’s probably not for you.

Several of the places we visited weren’t ready to welcome us when we showed up unannounced. To say the least, they’re busy. That was the case at Radius Community Health and Healing, an institutional building in a more residential part of the neighbourhood. Radius is a drop-in clinic and, as we’ll see, quite a bit more.

On a sunny weekday afternoon, more than a dozen people stood, sat or lay on the building’s front steps and truncated lawn. One lay on his back, shirtless, not moving visibly. Ghosh asked the man whether he was all right, asked again, finally nudged him. The man stirred, looked around. Ghosh apologized mildly for bothering him, then checked in on two other people who also weren’t moving. They turned out to be all right too.

Francesco Mosaico, Radius’s medical director, was on his way home for the day when we arrived, but we made plans to talk the next day. When I returned, I met Mosaico and Radius’s executive director, Tricia Smith, in her office.

I think it’s important to hear them out, because when drug use becomes the object of political debate, it’s natural to talk as though policy decisions are the main thing keeping people from getting well. This can lead to a lot of blame on one hand, and to excessive optimism on the other. In fact the biggest thing that keeps people from getting well is often the entire sum of their lives until now, compounded by the influence of drugs that are more potent than anything earlier generations had to deal with.

The most complex patients

Radius offers primary care to people “experiencing multiple barriers,” Smith said. That can include homelessness, addiction, severe mental health problems, criminal records. The centre’s team includes 12 family physicians and three psychiatrists. They currently see about 3,000 patients.

Radius has Western Canada’s only non-profit dental clinic. The centre runs a respite program for people who are not sick enough to be in acute care but are too sick to be managing independently on their own. It has a program for pregnant women experiencing homelessness. It runs on a harm-reduction model, so they don’t need to be drug-free to go into the program. It has an interdisciplinary Assertive Community Treatment team to help people with mental-health and substance problems find and stay in market apartments, with frequent assistance. There’s a supervised consumption site in the basement.

“In fact,” Smith said, “we actually have an exemption from the College of Physicians and Surgeons of Alberta to filter out and keep the most complex patients. The least complex, we refer elsewhere.” I couldn’t get care in Radius if I tried; they’d politely refer me elsewhere. They’re for the people who need the most help.

After my visit, Smith wrote to me to add another program to the list: Kindred House, which for more than 25 yearss has supported women and Trans women sex workers. “The women we see are from age 18 to 50, predominantly Indigenous, have intergenerational trauma, past/current trauma, substance use issues, often houseless or couch surfing,” Smith wrote.

Smith has been at Radius for three and a half years. While I was there, I asked her how work at Radius is going. “It’s going fabulously, honestly,” she said. She arrived early in the COVID pandemic, after eight years in Alberta government departments — which in turn followed 20 years as a Canadian Forces army nurse, including in combat zones. “I’m in the right place,” she said of Radius. “It felt like coming home.”

How come? “The staff, the team, the work, the dedication. It just feels like family. I missed that. Being in the military was a big thing. This work that this group does is just really amazing. The team is amazing and it’s hard, but it’s good work.”

And how’s the workload evolving? “Unfortunately, for this population, the struggles are only increasing, and the number of individuals that are experiencing those challenges is not getting less,” she said. “The workload isn’t going anywhere. It’s getting more difficult.”

“Especially in the last couple years, I don’t think things have ever been worse for the vulnerable population,” Mosaico, Radius’s medical director, added. The same housing crunch that has made homes less affordable for everyone has put thousands of the most vulnerable on the street. Results: more frequent frostbite or burns from lamps lit to keep from freezing. Body lice. Trauma from watching friends die. And to Mosaico’s astonishment, frequent shigella outbreaks.

“Shigella’s a bacteria that causes torrential bloody diarrhea. It can be treated with a single dose of antibiotics. But if you’re homeless and you don’t have a place to take care of yourself… 70 percent of the cases have had to be hospitalized in the last two years…. I mean, they’re talking about potentially calling it an endemic disease, and it’s a disease of destitution. You see it in refugee camps in developing countries, not in the capital of Alberta, you know?”

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Ten thousand times deadlier

Radius also works closely with the Alberta government to integrate its services with the “recovery-oriented system of care” that I told you about last week. There are two Radius staffers working at the Integrated Care Centre the police set up to replace the old, passive holding cells for overnight detention. There are two more at the Navigation Centre, which steers people toward social and government services. If there’s an Alberta model, they’re part of it. So I was fascinated by the response when I asked my hosts the basic question that sent me to Alberta: Why are so many people dying?

“I think it’s the nature of the drugs,” Mosaico said. “You know, people used to overdose and die. But I’ve been here 17 years. I think in the first 10 or 11 years it wasn’t very common to hear about overdoses by opioids. Every once in a while you’d hear about it, but it wasn’t a daily thing. Whereas now with fentanyl and carfentanil, it’s really dangerous.”

Carfentanil is 10,000 times more potent than morphine, 100 times more than fentanyl. The Edmonton Police won’t return stolen cars they recover until they’ve scrubbed them thoroughly, because even trace amounts of these drugs are too dangerous. “We’re finding clients who use methamphetamines and swear up and down they’re not taking opioids,” Mosaico said. “And then we do urine tests and it’s there. We think their dealers are lacing methamphetamine with fentanyl because it increases the addiction.”

The other big thing on his mind, Mosaico said, is that any program to guide users into recovery will bump up against the fact that different people have often lived starkly different lives.

93% 4+

“I don’t know if you’re familiar with Adverse Childhood Experiences — the ACEs study,” Mosaico said. I was, barely, but I needed a refresher.

The original study began in 1985 in San Diego, under Vincent Felitti, who ran an obesity clinic, and Rob Anda from the Centres for Disease Control. (If you want to learn more about the study, this article and this speech on Youtube are good places to start.)

“They surveyed 17,000 people,” Mosaico said. “They found, you know, if people had developmental trauma — so, trauma between the ages of 0 and 18 — and there are 10 different forms of trauma that the study bore out as being detrimental. Things like physical, emotional, sexual abuse; physical, emotional neglect; substance use in the family; untreated mental illness in the family; separation from biological parents; maternal figure being treated violently; and a household member going to jail.

“If those things occurred, you would just tally up the number of types of trauma and you’d get a score out of 10. What they found was, if you scored four or greater, that there seem to be adverse health effects in adulthood. And it wasn’t just the presence of addictions or mental illness. It was lung disease, heart disease, liver disease, certain forms of cancer, diabetes, obesity.” This is almost folk wisdom today, but at the time, Felitti and Anda were amazed at the strength of the correlations between childhood trauma and adult physical and mental health.

The original test has been widely replicated, and it usually finds that the proportion of people in a sample who’ve had four or more adverse childhood experiences is about 12%. So something like every eighth person you meet had a really difficult childhood, and while you can’t predict for individuals from statistical trends, there’s a good chance they’re still living with the fallout.

The team at Radius surveyed a large sample of the population under their care. The prevalence of high-risk ACE scores was about 93 percent, compared to 12 in the general population,” Mosaico said.

“Harvard has a center on the developing child, which has pulled together a lot of the science that explains the neurobiological link between the adverse trauma and the adverse health effects. They talk about limitations in the development of executive function, of decision-making, emotional regulation. Impulse control is underdeveloped, neuroanatomically in the brain. And instead what over-develops is the fight-or-flight response.

“So you’re dealing with a population that, because of their experiences, isn’t the same as the general population . And then that’s compounded by the fact that a high percentage of those clients who have high ACE scores also have traumatic brain injuries from living rough on the street. They also have adult trauma that compounds the childhood trauma. They have [fetal alcohol spectrum disorder], which impairs executive function even further.

“I hear these success stories and I think they’re wonderful, when you hear about people who have a difficult life and then they straighten up. And then, you know, they go back to their jobs and their families and they become leaders in their communities. But this is a population which is over-represented in every aspect of society, negatively as it were. In the prisons and child family welfare services. In the health system, you know, prevalence of HIV, tuberculosis, Hepatitis C, STIs, all that.

“And you look at them and you think, even if they managed to wait, you know, six months to get into an addiction recovery bed, after waiting for weeks to get into detox and they go through the program, what do they go back to? Most of them had to drop out of school. They have criminal records, which makes it hard to get a job. They’re disconnected and estranged from their families. They haven’t learned social skills.

“I had a client who lived in dumpsters for two and a half years. The fact that he just stayed housed — on income support — for the rest of his life was a huge win, right? It was important for his dignity, his quality of life. It’s just a matter of adjusting your expectations of what might actually be realistic.”

Dr. Larson writes

The idea for these stories goes back to February, when it first became clear to me that 2023 would be Alberta’s worst year for overdose fatalities. I asked the communications team at the University of Calgary for names of people to talk to. Many weeks went by, because sometimes it’s ridiculous how hard it is to extract myself from Ottawa routine. After I published the second article in this series, the one where Marshall Smith showed me all the stuff Alberta is building, I received an email from Dr. Bonnie R. Larson, who’s on faculty at the University of Calgary. She thought I should have talked to her, and she thought I was too credulous in reporting the Alberta government’s side. I asked if I could publish part of her email. Here it is.

What cannot be taken for granted is Mr. Smith’s view that his goals are different, somehow nobler, than those of us on the front line.  Smith paints a picture that front line providers’ priorities are at odds with his own.  His perspective is at once undemocratic, insulting, and arrogant, belittling those who are doing the hard work of keeping people alive every day.  

I will not have Smith speak for me in his suggestion that front liners lack system knowledge and that is why we support harm reduction. This ignores the excellent evidence supporting harm reduction interventions at the population level.  Smith seems to think he knows from whence I “enter this conversation”.  If so, why does he not engage me and my expert colleagues?  Where I “enter this conversation” is at 20 years of working with the affected community and 13 years of post-secondary education.  The only reason I am what Smith likes to dismiss as a “radical harm reduction activist”, is because the UCP, immediately upon taking office, set out to destroy harm reduction in Alberta.  Nobody would have ever needed to fight this soul-destroying battle in the first place if Smith hadn’t put Alberta squarely on its current path of destruction. Yes, we should hope for a better tomorrow but that doesn’t excuse ignoring the past and present.  

I would ask you to think about several additional factors that your analysis appears to ignore, including who actually benefits, in power and wealth, from Smiths’ system of so-called care?  DId you consider the other ways that the UCP policy direction is moving the entire publicly-funded system steadily towards profit?  Gunn (McCullough Centre) was a wonderful non-profit facility that helped many of my patients find their way to recovery from substance use disorders. While I agree that people should not have to pay for treatment, the question remains:  in whose pockets do those tax dollars ultimately land?

You report that Smith indicates that they are “monitoring” the entire system.  Where is the data from that monitoring?  They have had five years now to show some outcomes, but who am I, just a lowly street doctor, to ask for population data?  What I do know is that if deaths begin to decline, it is because so many are already gone.  You should ask to see the data about which Smith so proudly boasts.    

Smith’s entire premise that he is fixing the ‘addiction crisis’ is a fallacy.  Addictions are not increasing.  Deaths by drug poisonings are, however, and Smith’s circus is only making that worse.  Allow me to spell it out for you:  harm reduction addresses the drug poisoning crisis that is, no question, taking a horrific toll in Alberta and nationally.  Smith’s ROSC, in contrast, addresses a figmentary addictions crisis.    

One last tip. Medications used for opioid agonist treatment are not harm reduction, they are treatment.  Nobody here is against treatment or recovery.  But Marshall Smith is against harm reduction.  Why can’t we just have the full spectrum of care???  Polarization is created by politicians to benefit politicians.   

I don’t endorse everything Dr. Larson writes here. The data, or a lot of it, seems to me to be publicly available on the province’s impressive dashboard website. Use the tabs at the top of the page to navigate. And indeed, the story the dashboard tells is alarming, which, as I explained in this series’ first instalment, is why I flew west. But Larson’s years of front-line work has earned her, at the very least, a right of rebuttal.

Synthesis

On my last day in Edmonton, I met Monty Ghosh at Highlevel Diner, at the outer edge of the hip Strathcona neighbourhood on the south of the North Saskatchewan River. Highlevel is famous for its cinnamon buns, which, if I’m going to be honest, are noteworthy mostly for being large.

If the Alberta government and its most vociferous critics are thesis and antithesis, Ghosh tries to provide synthesis. He helped design the National Overdose Response Service, or NORS, which provides some of the emergency-response capability supervised consumption sites offer to people who aren’t near such a site or can’t use it for other reasons. He’s been critical of the Alberta government, but both sides keep lines of communication open.

I asked him about diverted safe supply — the idea that pharmaceutical opioids used in safe-supply programs in BC, principally hydromorphone tablets, are being sold or distributed away from their intended use. “I know it happens,” Ghosh said. “We sometimes get clients from British Columbia who come to Alberta to try to escape BC, because they’re looking for a fresh start. They’re looking for support and they’ll tell me themselves that they’ve diverted their safe supply.”

But what are the quantities? Trivial so far, Ghosh maintains. “Have I seen hydromorphone come into our province? Not at all, not yet.” This is the same thing I heard from Warren Driechel, the Edmonton deputy police chief.

Why do people divert their prescribed safe supply anyway? The answer Ghosh gave me was the answer I heard from everyone I asked. “They never used it. It just was not effective. The potency of the hydromorphone that they’re getting was nowhere near touching the fentanyl that they were using. It wasn’t dealing with the cravings, it wasn’t dealing with withdrawals, they felt it was useless. So what did they do? They sold it. They’re incredibly poor, they cannot afford their substance-use concerns and so therefore they supplement with revenue from hydromorphone.”

Before I flew to Edmonton, when Ghosh and I were trying to gauge on the phone what each of us thought of this infernal crisis, he figured out that I was interested in the differences between government policy in British Columbia and Alberta. “I’m not sure you want to hear this,” he said, “but I think it’s going to be bad everywhere.” I said that’s what I think too. Perhaps I surprised him.

I don’t know what happens next. Maybe things just stop getting worse everywhere on their own, for big complex reasons that resist easy analysis. Overdose deaths were lower last year in the United States, the capital of this hellscape, than the year before.

If not… well, we shall see. I wonder what happens in year six or seven of the effort the Alberta government is building. Is there resentment among people in ordinary hospitals and correctional facilities, who don’t have access to bespoke programs and personal attention? Does the ROSC system become bureaucratized after the first generation of administrators moves on?

Or does it start to win converts? David Eby, the NDP premier of British Columbia, has started putting distance between himself and his public-health advisors on legalization and safe supply. A new appointment in BC is being closely watched in Edmonton.

Or, conversely, does the Alberta recovery effort bump up against the limits imposed by the substances involved and by human nature? Reported recovery rates from addiction vary widely, depending in part on how you measure them. This paper puts the rate at less than 30%. If you even manage to double it, that still leaves a large cohort who aren’t getting better. Would their neighbours see them as people who “failed recovery” or “blew their chance?”

I won’t claim to know. I do hope that in the year ahead, more Canadians check their assumptions and stow their cheap certainties. Especially those who aspire to positions of leadership.

Marshall Smith. Photo: PW

PAUL WELLS

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Alberta’s system builder

The Alberta model, made in BC

“I, as you know, have been everywhere in this field, from eating out of garbage cans to this office,” Marshall Smith said. “So I have a deep respect for everybody who works along that continuum.”

We were sitting in the office at the Alberta Legislature reserved for chiefs of staff to Alberta premiers. That’s Smith’s current job. Premier Danielle Smith was probably nearby, though I didn’t see her on this trip. On a shelf behind Marshall Smith were two coffee mugs of different design, each bearing the inscription WAKE UP. SAVE LIVES. REPEAT.

Anyway, Marshall Smith (all future uses of “Smith” in this post will refer to him, unless I specify the premier) was talking about the continuum from dumpsters to the centre of power. “Where you work on that continuum obviously colours the way that you enter this conversation,” he said. “When you are standing on a sidewalk with a person in front of you, the solutions to that person’s problem look very different than what you might do to plan a broader system of care, for a large population of people.”

This was his way of anticipating criticisms he faces as a leading strategist behind Alberta’s emerging strategy for handling a deadly progression in opioid doses. Since he entered Alberta’s government as a more junior staffer in the government of former premier Jason Kenney in 2019, Smith has been working to put a much greater emphasis on recovery from addiction than on “harm reduction,” whose valuable goal is to keep drug users alive whether they recover or not. This makes him a bête noire among harm-reduction advocates. (You can read a mild critique of his efforts here; or a real scorcher here).

What Smith was saying was, in effect, If you work on the street, you’re going to be all about harm reduction, and I respect that. But he is working on drug policy for a whole province, and perhaps beyond, so he needs a broader perspective. “I’m a system builder. So I don’t have the luxury of just focusing on one particular substance. I have to worry about the whole population. I have to worry about the disease burden of addiction and drug use more broadly.”

He sees much to worry about. “Over the last 30 years in Canada, successive governments have failed miserably to anticipate and adequately address the type of services — both from a capital investment and an operating investment — to help people do this.” By “this,” he means escaping addiction. “We have not cared about people with mental health and addiction issues. And we had the ability to not care because up until the last six or seven years, the evidence of them was hidden away.”

Smith first started thinking about this when he was in British Columbia, where he began his recovery from a history of drug use. In 2018, at the BC Centre for Substance Use, Smith co-wrote a report with Dr. Evan Wood that called for a large new investment in facilities and programs to help people recover from addiction. The report is no longer on the BCCSU website, but you can download a copy here.

“It was a 39-point strategy to transform the system in British Columbia,” Smith recalled. “The government of British Columbia wasn’t interested in that strategy. They wanted to go a particular direction.

“So that report is now known as the Alberta model.”

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Marshall Smith in the dining hall of the Lakeview Recovery Community, opening in July. Photo: PW

In its first page, the Wood/Smith report said “British Columbia has long suffered because of the lack of an effective system to support individuals in and pursuing recovery from substance use disorders.” The system’s “overwhelming focus” was on keeping people alive rather than helping them get better. Wood and Smith wanted that to change.

The need for major new investments in addiction recovery was essentially uncontroversial in B.C. Indeed governments there still periodically announce they are making such investments. But Smith was perpetually unsatisfied with the scale of that commitment.

A year after BC’s new NDP government could-shouldered his report, Smith began working in the UCP government of Alberta’s then-new premier, Jason Kenney.

“Obviously we started off very modestly,” Smith said. “I worked in an office down in the basement. Mental health and addiction wasn’t a big deal. It really was very much a group of cubicles.”

Today, Alberta’s department of mental health and addiction is the seventh-largest ministry in the provincial government.

“The ROSC transformation that is going on in Alberta is massive. It is one of the most massive whole-of-government system transformations that I’ve seen,” Smith said. The premier chairs a ROSC committee of cabinet with seven ministers.

I guess I’d better unpack that acronym. ROSC stands for “recovery-oriented system of care,” a term that appeared in the 2018 report Smith co-wrote.

So you get the premier and her ministers of mental health and addiction, Indigenous relations, advanced education, health, community and social services, public safety and the attorney general meeting regularly to coordinate recovery policy. The premier’s chief of staff is on the file constantly. As I mentioned on Monday, he devoted a full day to explaining this broad effort to me.

“We spend enormous amounts of time and energy,” Smith said. “All of us live and breathe this. Anybody out there that thinks that we’re just, from a conservative perspective,  just cavalierly doing this, that just couldn’t be more untrue. We we are in this completely and totally. We monitor almost everything that goes on in the system.”

What are they working on? Smith said the “recovery” part of that “recovery-oriented system of care” jargon-ball gets most of the attention, because it draws attention to the contrast between harm-reduction and abstinence-based recovery models. But Smith is a wonk, and if anything he is more interested in the “system of care” part. His goal is to ensure that every interaction an opioid user has with the modern government apparatus is designed to encourage recovery from dependency. Since people who use drugs tend to bump up against the state a lot, Alberta’s emerging system has a lot of moving parts. The goal is to hook the parts up more effectively.

One of the other men in Smith’s office, Dr. Nathaniel Day, chimed in. He’s been the lead strategist on substance use at Alberta Health Services. He’s an important Smith collaborator.

“Across Canada,” he said, “the system of care for people with addiction has been fragmented, poorly thought out — convenient.” He meant services had generally only been provided when, and where, it was easy for government to provide them. “If you look at opioid dependency treatment, if you lived in a suburban or rural community, it didn’t matter that you had an opioid use disorder. Tough. We had no services for you.”

Day designed the Virtual Opioid Dependency Program, which provides online consultations to patients anywhere in Alberta, and if needed, prescriptions to medications that can be filled at local pharmacies. For patients without coverage, the medication is free and if their local pharmacist has it in stock, available on the day of the call.

“We went in and said, enough is enough,” Day said. “What would be good enough for you and your family? And how do we take that to everybody?”

Which medication? “In this province, we’re huge fans of gold-standard opioid-replacement medications, and we use it a lot,” Smith said. “We have Sublocade, which is something that other provinces don’t have because it’s very expensive. It’s the injectable version of Suboxone. It’s a subcutaneous injection, it goes under the skin, it lasts for 30 days, where the oral is 24-hour. So that’s a thousand bucks a shot, and we pay for that.”

An obvious point about this is that these so-called opioid agonist treatments, or OATs, are big-time harm reduction. They greatly reduce both withdrawal symptoms and highs. One question that I still have, after watching everything Smith and the Alberta government are doing on drug recovery, is whether other provinces could afford to match it.

Running into those institutions

VODP is useful for people who are able to reach out for help from home. But other potential beneficiaries are distracted, or in distress. Very often they run into the police.

“So we took that technology” — the virtual access to physicians and treatment — “and we gave it to the 34 police agencies that we have in the province,” Smith said.

“We said to the officers, ‘If you encounter somebody who has an opioid-use disorder, you can get them started on opioid-use medication. You can, officer. Here’s the phone number to call. Put them on. We make the arrangements. They go to the pharmacy, right then and there. If they’re on the street, that can be done right in the back of a police car.

“If they are in custody at the cell block and they go into the cell block, we have put paramedics in every cell block in Alberta. So the first thing that happens to somebody when they’re arrested and they go into into municipal cells, they’re met by a paramedic that says, ‘Let’s talk about your substance use. Are you an opioid user? We can offer you immediate treatment right now. Right here. Would you like to do that?’ Through our police programs, we’re probably up to like 4,000 people who have taken us up on that.”

That’s what you can get done in a police cruiser or a holding pen. Lots of people go much further into the correctional system than that. So does Smith’s system of care.

“[Alberta’s] focus on corrections and police right now, admittedly, is the opposite of what some other jurisdictions are focusing on,” Smith said. If anything this was an understatement. A major argument for decriminalization and safe supply is that the last thing a drug user needs is the stigma of a criminal record. Other jurisdictions, Smith said, “are running away from those institutions when they should be running into those institutions.

“I’ll give you a very direct example why.

“We know, from the 2017 coroner’s report in Alberta that 40 percent of the people who died [of opioid-related causes] were in custody in the year prior to their death. That’s a really important piece of information, because it tells me I have a big chunk of population there that — if I can get at them, and if we can change the way that they experience this process — we can make a big dent in these numbers.”

A lot of people in the correctional system have substance-use disorder, even if that’s not what they’re in for. “We said, ‘Let’s really do a different way of thinking on this,’” Smith said. “Even though Corrections is a public-safety agency, we want the Ministry of Mental Health and Addiction to take over all Corrections health care.”

Perhaps four in five detainees, he said, “have alcoholism, addiction and mental-health issues. They’re all pooled up in one place and they’re not doing anything. They’ve got nothing but time on their hands. And I don’t have to build a new building? You’re kidding me! This is fantastic! Why wouldn’t I just put therapists in? So we now have treatment programs inside correctional centers.”

Of course a lot of places do programs for inmates. “But what they’re going to show you when you unpack that is, ‘Well, we give them this workbook,’” Smith said. “What they’re not doing is the deep transformative, therapy work that is necessary. And honestly, Paul, our Therapeutic Living Units are probably the best treatment programs we have in Alberta.”

With that, we piled into Smith’s SUV — Smith, Day and the third member of Smith’s team that day, a physician and consultant named Dr. Paul Sobey. A half-hour later we arrived at the Fort Saskatchewan Correctional Centre, northeast of Edmonton.

Here we visited the Therapeutic Living Unit, a full-time addiction-recovery program for 21 women who are housed separately from the general inmate population. That’s about 10% of the total population of women at Fort Saskatchewan. The program opened in February. Participants, who must apply, run through a 12-hour daily program of activity: morning check-in meetings, physical exercise, twice-daily smudge ceremonies reflecting the large Indigenous population in the correctional system, frequent meetings of Alcoholics Anonymous and Narcotics Anonymous as well as the more recently developed SMART Recovery system. Participants are rarely alone during daylight hours. The program is designed to last for months, which struck me as an unusually long time for a recovery program.

Four of the program’s participants sat on a sofa and talked about their experience in the program. “I’ve been wondering and wondering if a program like this was going to happen,” one said.

“It’s like an answered prayer, honestly,” said another. “So I would just encourage you to keep opening places like this.”

That’s the plan. “We’ve got 12 correctional centers in Alberta,” Smith told me before our road trip. “Our goal is to have Therapeutic Living Units [in all of them]. There will come a time where we have whole correctional centers that are working on this model, right? This requires massive intervention, not tinkering around the edges. This is generational change in the way that we do corrections in Alberta.”

Connections

All of the four young women we heard from said they’re nervous about what happens when they get out of detention. Old acquaintances can encourage a return to old habits. Which is part of the reason why Alberta is also building a network of live-in Recovery Communities, long-term residential rehab programs to reinforce the lessons learned in the TLUs — or to help other people begin recovery if they didn’t arrive via the correctional system.

Once the system is fully built in 2027, “every correctional centre will have a sister Recovery Community,” Smith said. “That’s why we’re building 11 of them around the province. Five of them are on First Nations, in partnership with the First Nations.”

Here’s where the system starts to look like a system. After all, in the broadest outlines nothing’s new here. People in prisons have long received addiction counselling, and the Alberta government and various private groups have long run rehabs. But for the longest time, these assorted parts of the system could barely talk to one another. So the chances of a seamless transition from the correctional system to recovery care were lousy. They’re still not great, because the system is still being built, but the goal is a seamless network of care.

“Services in 2018, 2019 were very disconnected,” Warren Driechel, the Edmonton Police Service deputy chief we met the other day, told me. The bureaucratic runaround that we all have to face can be brutal on people with high needs and impaired function. Say you want to get on AISH, an income-support program for people with a medical condition. To do that, you need a doctor’s appointment. To get one, you need identification. To get ID, you need an address.

Public officials are working to provide services that match that complexity.

In January 2021, the EPS launched a “HELP Unit” to refer people to social services instead of just arresting them.

In September 2023, the police replaced the old holding cells where intoxicated people could dry out and then get dumped back on the street with an Integrated Care Centre where they could connect with social services that operate right in the centre.

And in January 2024, after many of the tent encampments were dismantled, a new Navigation and Support Centre became the city’s hub for providing medical, legal and bureaucratic help for people who have often been bereft.

The Nav Centre has nine shelter beds in the back where people can rest, if needed, while on-site staff and volunteers process their files. (Pets are welcome, unlike in some of the city’s shelters.) The centre has the province’s only on-site Service Alberta photo-ID station. On the day I visited, the Nav Centre assisted 50 people, with 24 visiting the desk run by the Hope Mission, 10 being helped by staff from Radius Health, 12 by the provincial department of mental health and addiction.

Everything old is new

Our final stop was the Lakeview Recovery Community outside Gunn, northwest of Edmonton. When it opens in July, it’ll be the third or fourth in a network of such long-term residential programs. Lethbridge and Red Deer have been open for a while. The goal is to have 11 centres up and running across the province by 2027. Smith hopes that once the full network of centres is open, long wait times in Red Deer and Lethbridge will shrink, perhaps to the point where some beds will be available on-demand.

Each recovery community has its quirks. Lakeview will be for men only. Five of the centres will be on Indigenous land. The minimum stay will be four months, with some residents staying for up to a year. That’s a long stint for a rehab; in some private rehabs, it’s unusual to stay for even a month. In theory every day you spend with a combination of counselling, group therapy, twelve-step programs and medical care will increase your chances of success. No resident will pay for their stay at any recovery community. It’s covered by the government.

Work crews have been renovating the Lakeview site since 2022. It’s an impressive place, roomy and bright, with rooms where residents can meet visiting family, a huge kitchen where residents will learn cooking skills, and a dispensary for opioid agonist treatment. Residents will share bungalows while they’re in the program, five or six to a house.

But it didn’t just come into existence. What’s now Lakeview began its existence as the McCullough Centre for homeless World War II veterans. It had been operating for years as an addiction rehab centre when Jason Kenney’s government closed it in 2021. When the government announced the site’s eventual reopening barely a year later, observers were baffled. Closing the centre fit a narrative about a government that put the bottom line over Albertans’ wellbeing. Refurbishing and reopening it was.. harder to explain. Fitting it into a network of nearly a dozen such centres that will, themselves, be better connected to street-level services and to the corrections system… well, we’ll see, won’t we?

I’m conscious of ending this installment in my series on opioids in Alberta on an ambivalent note. I simply don’t know how this will turn out. My first article, earlier this week, was about the scale of the challenge. This one is about the scale of the response. It’s impressive. It’s getting attention across the country. Sobey, the physician who was the third member of our little party as we toured the region’s facilities, has a consulting firm whose aim is to design recovery-oriented systems of care to any government that wants to start the conversation. His phone pinged with an inquiry from another provincial government while we were visiting the Fort Saskatchewan prison. These ideas may come soon to a province near you.

What we don’t know yet is whether they’ll work, or how well. In the third and final installment in this series, I’ll discuss a few reasons to reserve judgment.

But what Alberta is trying is, in many ways, not heretical. Nobody thinks it’s great design to leave desperate people to wander helplessly thorugh a piecemeal hodge-podge of social services and treatment options, with police and corrections hovering over it all as an aloof menace. Smith, his boss the premier, and several government departments are trying to build a better system.

There is room for many devils in the details. But if federalism is supposed to be a laboratory for testing different approaches to thorny problems, Alberta is testing this approach ambitiously. Watching Marshall Smith, I found myself wondering what other intractable governance problems could benefit from the sustained attention of an empowered senior staffer, a supportive head of government, and ministers and public servants working in close coordination.